Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care

Investigating the role and impact of expert nurses

This literature review was conducted to identify the attributes of an expert nurse and the direct and indirect impact they have on patient care, health-care organisations and nursing. Given the loss of expert nursing posts as a result of NHS deficits, there is an urgent need to differentiate between a range of expert nursing roles and how these contribute to positive patient and health outcomes and organisational efficiency. The focus of the literature search was on developments in the UK and the results indicated that ambiguity and confusion exist around the terminology and definitions associated with expert nurses. Research shows that expert nurses have a positive impact on patient care and organisational efficiency. However, a lack of clarity leads to a dilution of expert nursing roles and nurse expertise. There is a need for national guidance on the skills required of expert nurses and the necessity of considering the formal protection of nursing titles.

Therapist variation within randomised trials of psychotherapy: implications for precision, internal and external validity

Nesting of patients within therapists in psychotherapy trials creates an additional level within the design. The multilevel nature of this design has implications for the precision, internal and external validity of estimates of the treatment effect. Prior to or during a trial, psychotherapies are allocated to therapists and therapists are assigned to patients such that the therapist becomes part of the causal pathway from the intervention to the patient. It is therefore important to consider not only the relationship between interventions and patients but also relationships between interventions and therapists and between therapists and patients. Research designs comparing the effects of therapeutic approaches, therapist characteristics and packages of the two can be unified by viewing therapists as an important source of variability within psychotherapy outcome studies. Methodological considerations arising from therapist variation will be discussed, drawing together and building upon the associated psychotherapy and statistical literatures. Parallels will also be made with related designs and methods of analysis.

"An honest tale speeds best, being plainly told": another look at health spending and the supply of physicians

Claims that the current physician resource shortage is due to the reduced work effort of physicians are misleading and ignore important trends, namely the demographic changes within the profession, the growth in non-physician spending that has outpaced spending on physicians and the relative decline in spending on physician services over the past 20 years. Such data make it difficult to support Evans's and McGrail's (2008) assertions, which distract from more fruitful policy discussions about eliminating the current shortage of physicians, integrating non-physician health providers into medical practice and otherwise meeting the growing demand for health services.

Nurse practitioners substituting for general practitioners: randomized controlled trial

AIM

This paper is a report of a study conducted to evaluate process and outcomes of care provided to patients with common complaints by general practitioners or specially trained nurse practitioners as first point of contact.

BACKGROUND

Studies in the United States of America and Great Britain show that substituting nurse practitioners for general practitioners results in higher patient satisfaction and higher quality of care. As the American and British healthcare system and settings differ from that in The Netherlands, a Dutch trial was conducted.

METHODS

A total of 1501 patients in 15 general practices were randomized to consultation by a general practitioner or a nurse practitioner. Data were collected over a 6-month period in 2006 by means of questionnaires, extracting medical records from practice computer systems and recording the length of consultations.

FINDINGS

In both groups, the patients highly appreciated the quality of care. No statistically significant differences were found in health status, medical resource consumption and compliance of practical guidelines in primary care in The Netherlands. Patients in the NP intervention group were more often invited to re-attend, had more follow-up consultations and their consultations took statistically significantly longer.

CONCLUSION

Nurse practitioners and general practitioners provide comparable care. Our findings support an increased involvement of specially trained nurse practitioners in the Dutch primary care and contribute to knowledge of the effectiveness of care provision by nurse practitioners from a national and international perspective.

Nurse practitioners and medical practice: opposing forces or complementary contributions?

PURPOSE

The medical profession in Australia has expressed concern about the expansion of nursing practice into areas that are traditionally the domain of medicine. Particular apprehension is raised in relation to the prescription of medications. This paper will consider and critique the argument that the standard of care provided by a nurse practitioner would be of lesser quality than that provided by a medical practitioner.

CONCLUSIONS

Despite the medical profession's opposition for nurse practitioner roles, there is little evidence suggesting that the quality of services offered by a nurse practitioner would be inferior.

PRACTICE IMPLICATIONS

Available evidence suggests that care and treatment from nurse practitioners in primary health care is equal to that provided by medical practitioners.

Structures of care in the clinics of the HIV Research Network

As the HIV epidemic has evolved to become a chronic, treatable condition the focus of HIV care has shifted from the inpatient to the outpatient arena. The optimal structure of HIV care in the outpatient setting is unknown. Using the HIV Research Network (HIVRN), a federally sponsored consortium of 21 sites that provide care to HIV-infected individuals, this study attempted to: (1) document key features of the organization of care in HIVRN adult clinics and (2) estimate variability among clinics in these parameters. A cross-sectional survey of adult clinic directors regarding patient volume, follow-up care, provider characteristics, acute patient care issues, wait times, patient safety procedures, and prophylaxis practices was conducted from July to December 2007. All 15 adult HIVRN clinic sites responded: 9 academic and 6 community-based. The results demonstrate variability in key practice parameters. Median (range) of selected practice characteristics were: (1) annual patient panel size, 1300 (355-5600); (2) appointment no-show rate, 28% (8%-40%); (3) annual loss to follow-up, 15% (5%-25%); (4) wait time for new appointments, 5 days (0.5-22.5), and follow-up appointment, 8 days (0-30). The majority of clinics had an internal mechanism to handle acute patient care issues and provide a number of onsite consultative services. Nurse practitioners and physician assistants were highly utilized. These data will facilitate improvements in chronic care management of persons living with HIV.

Substitution of specialized rheumatology nurses for rheumatologists in the diagnostic process of fibromyalgia: a randomized controlled trial

OBJECTIVE

To evaluate the substitution of specialized rheumatology nurses for rheumatologists in diagnosing fibromyalgia (FM).

METHODS

Referred patients with FM symptoms (n = 193) were randomized to a study group diagnosed by a specialized rheumatology nurse (SRN group, n = 97) or to a control group diagnosed by a rheumatologist (RMT group, n = 96). SRN patients were seen within 3 weeks by a nurse who took structured history and initiated routine laboratory tests. During a 5-minute supervision session, the rheumatologist was informed by the nurse about medical history, performed a brief physical examination, and confirmed or rejected the nurse's diagnosis. RMT patients were seen by a rheumatologist after a regular waiting period of 3 months. Outcome measures were initial agreement between the nurse and rheumatologist in the SRN group, final diagnosis after 12-24 months of followup, patient satisfaction, and diagnostic costs.

RESULTS

The mean waiting time after randomization was 2.8 and 12.1 weeks in the SRN and RMT groups, respectively. Eight RMT patients cancelled their appointments because of the waiting time. Excellent agreement (kappa = 0.91) between rheumatologists and nurses was found. After 12-24 months of followup, none of the initial diagnoses were recalled in either group. SRN patients were significantly more satisfied than RMT patients. Mean diagnostic costs were lower in the SRN group (euro219) than in the RMT group (euro281) (95% uncertainty interval euro-103, euro-20).

CONCLUSION

Substituting specialized nurses for rheumatologists in the diagnostic process of FM is a trustworthy and successful approach that saves waiting time, provides greater patient satisfaction, and is cost-effective.

Effects of COPD self-care management education at a nurse-led primary health care clinic

Chronic obstructive pulmonary disease (COPD) is disabling, with symptoms such as chronic cough, phlegm, wheezing, shortness of breath and increased infections of the respiratory passage. The aim was to examine the effects of a structured educational intervention programme at a nurse-led primary health care clinic (PHCC) on quality of life (QoL), knowledge about COPD and smoking cessation in patients with COPD. This study had an experimental design in which 52 patients with COPD from a Swedish primary care setting were randomized into two groups (intervention or control). Both groups received standard care but patients in the intervention group were also offered two visits to a nurse specialized in COPD care. The purpose of the visits was to increase the patients' self-care ability and their knowledge about COPD. The study was approved by the local Research Ethics Committee. Data were collected using two questionnaires, one pertaining to knowledge about COPD and smoking habits and St. George's Respiratory Questionnaire, addressing how QoL was affected by the patients' respiratory symptoms. The intervention and control groups answered both questionnaires on their first and last visits to the PHCC. A statistically significant increase was noted in the intervention group on QoL, the number of patients who stopped smoking and patients' knowledge about COPD at the follow-up, 3-5 months after intervention. However, a confounding factor may have been that one of the researchers (Eva Osterlund Efraimsson), as a nurse in the PHCC, performed the intervention. This implies that patients were in a dependent relationship which may have affected the responses in a favourable direction. Our findings show that conventional care alone did not have an effect on patients' QoL and smoking habits. Instead, the evidence suggests that a structured programme with self-care education is needed to motivate patients for life-style changes.

Critical appraisal of the literature on economic evaluations of substitution of skills between professionals: a systematic literature review

OBJECTIVE

Substitution of skills has been introduced to increase health service efficiency, but little evidence is available about its cost-effectiveness. This systematic review aims to identify economic evaluations of substitution between professionals, to assess the quality of the study methods applied and to value the results for decision making.

METHODS

Publications between January 1996 and November 2006 were searched in Medline, Cochrane, Cinahl, database of Health Technology Assessments, EPOC and Embase. Randomized controlled trials (RCTs), cost-benefit analysis, interrupted time series design and systematic reviews were selected. The methodological quality of the papers was reviewed, using the critical appraisal of Drummond and the EPOC list.

RESULTS

Eleven studies were finally included of 7605 studies: three cost-effectiveness studies, three cost-minimization studies and five studies related to partial economic evaluations. Small numbers of participating professionals and several limitations in the cost valuation and the measurement of costs were identified.

CONCLUSIONS

Several potential limitations influence the validity and generalizability. Full economic evaluations per se are of limited value for making decisions about substitution of skills. The tenuous relationship between structural, process and outcome variables is not sufficient investigated. For meaningfully placing the costs and consequences of substitution of skills in the context of health care and generating relevant data for decision making, it is strongly recommended to combine an economic evaluation (RCT) with an observational longitudinal study.

Factors associated with enablement in general practice: cross-sectional study using routinely-collected data

BACKGROUND

Quality-improvement activities are most often focused on clinical quality indicators. However, patient evaluations are important additional indicators of the quality of general practice consultations, including measures of satisfaction or enablement (that is, the extent to which the consultation enhances the patient's feelings of confidence and ability to cope). There is limited evidence concerning factors associated with enablement in UK general practice.

AIM

To identify patient and practice characteristics associated with enablement scores following general practice consultations.

DESIGN OF STUDY

Cross-sectional survey using a large routinely-collected dataset of patient evaluations of general practice (190,038 individual patient responses).

SETTING

A total of 1031 UK general practices.

METHOD

Relationships between health, demographic factors, evaluations of general practice care, and patient self-reported enablement were estimated using multiple regression.

RESULTS

The primary predictor of enablement was positive patient evaluation of the GPs' communication. Reported continuity of care accounted for a lower proportion of the variance. Of the included patient demographic variables, ethnicity was a key predictor, with patients from minority ethnic groups reporting greater enablement once other factors were controlled.

CONCLUSION

The current results provide support for the construct validity of the enablement measure. However, if enablement is to become a valid and useful measure of quality, it is necessary to understand the mechanisms by which enablement is increased in certain patients and practices. Detailed qualitative research may also be required to explain the relatively high scores of ethnic minority responders, despite lower overall satisfaction scores, and to understand why some items included in the enablement measure are regarded as 'not applicable' by a substantial minority of patients.

Impact of physician assistant care on office visit resource use in the United States

OBJECTIVE

To investigate whether the use of physician assistants (PAs) as providers for a substantive portion of a patient's office-based visits affects office visit resource use.

DATA SOURCE

Medical Expenditure Panel Survey (MEPS) Household Component data from 1996 to 2004.

STUDY DESIGN

This retrospective cohort study compares the number of office-based visits per year between adults for whom PAs provided >or=30 percent of visits and adults cared for by physicians only.

DATA COLLECTION/EXTRACTION METHODS

The Agency for Healthcare Research and Quality collects MEPS data using methods designed to produce data representative of the U.S. noninstitutionalized civilian population. Negative binomial regression was used to compare the number of visits per year between persons with and without PA care, adjusted for demographic, geographic, and socioeconomic factors; insurance status; health status; and medical conditions.

PRINCIPAL FINDINGS

After case-mix adjustment, patients for whom PAs provided a substantive portion of care used about 16 percent fewer office-based visits per year than patients cared for by physicians only. This difference in the use of office-based visits was not offset by increased office visit resource use in other settings.

CONCLUSIONS

Results indicate that the inclusion of PAs in the U.S. provider mix does not affect overall office visit resource use.

Examining the potential of nurse practitioners from a critical social justice perspective

Nurse practitioners (NPs) are increasingly called on to provide high-quality health-care particularly for people who face significant barriers to accessing services. Although discourses of social justice have become relatively common in nursing and health services literature, critical analyses of how NP roles articulate with social justice issues have received less attention. In this study, we examine the role of NPs from a critical social justice perspective. A critical social justice lens raises morally significant questions, for example, why certain individuals and groups bear a disproportionate burden of illness and suffering; what social conditions contribute to disparities in health and social status; and what social mandate NPs ought to develop in response to these realities. In our analysis, we draw on lessons learned from the initial Canadian experience with the introduction of NPs in the 1970s to consider the renewed and burgeoning interest in NPs in Canada, Australia and elsewhere. As we argue, a critical social justice perspective (in addition to the biomedical foci of NP practice) will be essential to sustaining long-term, socially responsive NP roles and achieving greater equity in health and health-care.

What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review

OBJECTIVES

To review and draw together the existing research evidence to assess the impact of advanced primary care nursing roles, particularly first contact nursing roles, for patients, nurses themselves and their colleagues in order to highlight salient issues for policy, practice and research.

BACKGROUND

Internationally, nurses' roles continue to expand in response to doctor shortages and policy drives to provide effective and efficient health services. A body of research exists from which to evaluate the impact of advanced nursing roles on various dimensions of healthcare delivery and organisation.

DESIGN AND DATA SOURCES

Medline, CINAHL, Applied Social Sciences Index and Abstracts, British Nursing Index, Cochrane Library, EMBASE, National Research Register, and PsycINFO databases were searched, including relevant websites. Studies were included if published in English and relevant to the primary/community care setting. Of a total of 211 papers identified, 88 were of relevance and included in the review.

RESULTS

Nurses working in many advanced primary care roles such as acute/minor illness, minor injury and long-term conditions provide safe and effective care, and patient satisfaction is generally high. Many factors influence patient satisfaction with, and access to, such services but are little understood. Evidence on cost-effectiveness, efficiency and impact on other health care professionals is inconclusive though research suggests the introduction of extended roles can create uncertainty and intra-/inter-professional tensions.

CONCLUSIONS

Evidence is of variable quality, often ignoring potentially important effect mediators such as the experience and educational level of advanced nurses, the effect of service 'maturation', organisational characteristics and differing patient preferences. The complex range of factors that influence patient satisfaction, access and outcomes of care need further investigation. Recent UK developments in nurse prescribing and the introduction of a national post-registration competency framework may improve working relations and patient understanding and experience of advanced nursing roles in primary care.

Asthma and COPD in primary health care, quality according to national guidelines: a cross-sectional and a retrospective study

BACKGROUND

In recent decades international and national guidelines have been formulated to ensure that patients suffering from specific diseases receive evidence-based care. In 2004 the National Swedish Board of Health and Welfare (SoS) published guidelines concerning the management of patients with asthma and COPD. The guidelines identify quality indicators that should be fulfilled. The aim of this study was to survey structure and process indicators, according to the asthma and COPD guidelines, in primary health care, and to identify correlations between structure and process quality results.

METHODS

A cross-sectional study of existing structure by using a questionnaire, and a retrospective study of process quality based on a review of measures documented in asthma and COPD medical records. All 42 primary health care centres in the county council of Ostergötland, Sweden, were included.

RESULTS

All centres showed high quality regarding structure, although there was a large difference in time reserved for Asthma and COPD Nurse Practice (ACNP). The difference in reserved time was reflected in process quality results. The time needed to reach the highest levels of spirometry and current smoking habit documentation was between 1 and 1 1/2 hours per week per 1000 patients registered at the centre. Less time resulted in fewer patients examined with spirometry, and fewer medical records with smoking habits documented. More time did not result in higher levels, but in more frequent contact with each patient. In the COPD group more time resulted in higher levels of pulse oximetry and weight registration.

CONCLUSION

To provide asthma and COPD patients with high process quality in primary care according to national Swedish guidelines, at least one hour per week per 1000 patients registered at the primary health care centre should be reserved for ACNP.

Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants

PURPOSE

The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician's assistants (PAs), or neither, and which practice attributes contribute to any differences in care.

METHODS

This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs.

RESULTS

Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A(1c) levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P <or= .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A(1c) levels (66% vs 49%) and lipid levels (80% vs 68%) (P<or=.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices.

CONCLUSIONS

Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.

Nurse case management program of chronic pain patients treated with methadone

Methadone treatment in chronic pain patients is still limited owing to misconceptions about addiction, safety, and its unique pharmacokinetic and pharmacodynamic properties. Nevertheless, patients with chronic noncancer pain are frequently treated with methadone at our Pain Centre either as the first opioid of choice, for specific pain conditions, or as a second-line opioid in patients developing tolerance or intractable side effects with other opioids. The aim of this study was to examine whether a nurse case management program of chronic pain patients treated with methadone is feasible and safe in trying to improve patients' care in an ambulatory setting. This program consisted of three phases: initial primary education session, telephone follow-up during methadone titration, and a subsequent maintenance period. The nurse case manager functioned autonomously and when required reported to and consulted the physician. The study included 75 subjects and was done over a nine-month period by completing follow-up questionnaires for every call. Of a total of 194 recorded calls, 41% were unscheduled. Forty-four percent of phone calls resulted in a methadone increase and 11% led to a decrease or cessation of methadone. No patients developed serious morbidity or mortality. Fifty-seven percent of patients were either satisfied or very satisfied with their treatment. A nurse-led case management program of methadone in chronic pain patients can improve patient care in an ambulatory setting.

Migraine and chronic daily headache management: implications for primary care practitioners

AIMS AND OBJECTIVES

The aim of this paper is to outline the classifications of migraine and chronic daily headaches (i.e. headaches occurring at more than 15 days per month) and briefly describe their epidemiology and management. After outlining the patients' management behaviours, this review paper discuss the implications for primary care practitioners, including general practitioners and nurses. Finally the paper sets out current resources for headache education for healthcare practitioners.

BACKGROUND

There is a scarcity of recent literature about migraine and chronic daily headache in primary care and of the evidence base for best practice. Patients with migraine and headache may see a variety of healthcare professionals and may not always be accessing the best sources of help.

METHODS

Various databases were searched, such as CINAHL, Cochrane, Medline, MedlinePubmed and the BMJ. In addition, manual searches were conducted by following on cited references from papers read.

RESULTS

The results of the literature reviews were critically read and evaluated by the team and the results are discussed in the critical review presented in this paper.

RELEVANCE TO CLINICAL PRACTICE

The paper proposes multidisciplinary working in relation to migraine and headache management in primary healthcare, using an evidence-based approach that stresses the importance of making the correct diagnosis, patient focused management and appropriate referrals to appropriate agencies to maximize benefits for patients.

The core role of the nurse practitioner: practice, professionalism and clinical leadership

AIM

To draw on empirical evidence to illustrate the core role of nurse practitioners in Australia and New Zealand.

BACKGROUND

Enacted legislation provides for mutual recognition of qualifications, including nursing, between New Zealand and Australia. As the nurse practitioner role is relatively new in both countries, there is no consistency in role expectation and hence mutual recognition has not yet been applied to nurse practitioners. A study jointly commissioned by both countries' Regulatory Boards developed information on the core role of the nurse practitioner, to develop shared competency and educational standards. Reporting on this study's process and outcomes provides insights that are relevant both locally and internationally.

METHOD

This interpretive study used multiple data sources, including published and grey literature, policy documents, nurse practitioner program curricula and interviews with 15 nurse practitioners from the two countries. Data were analysed according to the appropriate standard for each data type and included both deductive and inductive methods. The data were aggregated thematically according to patterns within and across the interview and material data.

FINDINGS

The core role of the nurse practitioner was identified as having three components: dynamic practice, professional efficacy and clinical leadership. Nurse practitioner practice is dynamic and involves the application of high level clinical knowledge and skills in a wide range of contexts. The nurse practitioner demonstrates professional efficacy, enhanced by an extended range of autonomy that includes legislated privileges. The nurse practitioner is a clinical leader with a readiness and an obligation to advocate for their client base and their profession at the systems level of health care.

CONCLUSION

A clearly articulated and research informed description of the core role of the nurse practitioner provides the basis for development of educational and practice competency standards. These research findings provide new perspectives to inform the international debate about this extended level of nursing practice.

RELEVANCE TO CLINICAL PRACTICE

The findings from this research have the potential to achieve a standardised approach and internationally consistent nomenclature for the nurse practitioner role.

Methods for analyzing cost effectiveness data from cluster randomized trials

BACKGROUND

Measurement of individuals' costs and outcomes in randomized trials allows uncertainty about cost effectiveness to be quantified. Uncertainty is expressed as probabilities that an intervention is cost effective, and confidence intervals of incremental cost effectiveness ratios. Randomizing clusters instead of individuals tends to increase uncertainty but such data are often analysed incorrectly in published studies.

METHODS

We used data from a cluster randomized trial to demonstrate five appropriate analytic methods: 1) joint modeling of costs and effects with two-stage non-parametric bootstrap sampling of clusters then individuals, 2) joint modeling of costs and effects with Bayesian hierarchical models and 3) linear regression of net benefits at different willingness to pay levels using a) least squares regression with Huber-White robust adjustment of errors, b) a least squares hierarchical model and c) a Bayesian hierarchical model.

RESULTS

All five methods produced similar results, with greater uncertainty than if cluster randomization was not accounted for.

CONCLUSION

Cost effectiveness analyses alongside cluster randomized trials need to account for study design. Several theoretically coherent methods can be implemented with common statistical software.

Impact of nurse prescribing: a qualitative study

AIM

This paper is a report of an investigation of the impact of prescribing on a group of recently qualified nurse prescribers in the United Kingdom.

BACKGROUND

The creation of advanced nursing roles, and specific skills such as nurse prescribing, has resulted in nurses taking on roles that have traditionally been associated with doctors. The non-doctor prescribing initiative is continually developing and many nurses are now able to prescribe independently from almost the same range of medicines as doctors. Despite the advantages that appear to stem from nurses prescribing, some nurse researchers have been cautious about the impact that prescribing may have on the nursing profession.

METHOD

Interviews were conducted during 2005 and 2006 with 45 nurse prescribers. All nurses had successfully qualified and registered as prescribers. Interviews were analysed thematically in line with the principles of grounded theory.

FINDINGS

Prescribing allows nurses to overcome difficulties in the healthcare system that previously delayed patients' access to medicines. Prescribing is viewed as more than an 'add on' to current roles, it complements many aspects of nursing and integrates previously diffuse aspects of the nursing role. This enables nurses to adopt a more holistic approach to patient care and prescribing. Prescribing has the potential to increase job satisfaction and autonomous working, with the result that nurses are more likely to involve patients in decision-making about their care.

CONCLUSIONS

Prescribing enhances nurses' knowledge about medication and increases their confidence to engage in prescribing decisions across the healthcare team. Nurse prescribing has the potential to improve service-user care, enhance collaboration and widen discussions about medicines. However, team members need to be prepared for the impact nurse prescribing could have on the dynamics of the multidisciplinary team. Preparatory information about nurse prescribing should be provided to all team members by trainee nurse prescribers. Information could include details about the proposed scope of future prescribing roles, allowing team members to consider how their roles could develop.

Dutch Women's Perceptions of Childbirth in the Netherlands

PURPOSE

To explore the lived experience of childbirth in Dutch women who had given birth at home in the Netherlands.

METHODS

Qualitative study using audiotaped interviews with 14 women.

RESULTS

Themes included the advantages of giving birth in the home, where the women felt more in control of their environment; the difficulty and normalcy of the pain associated with giving birth; the feelings of fulfillment and empowerment that come with childbirth and motherhood; and the importance of the supportive role of the midwife-caregiver.

NURSING IMPLICATIONS

Women in a culture different from that of the United States who gave birth at home felt fulfilled and empowered by the experience. These results can help U.S. nurses more fully understand the meaning of childbirth in a different culture and may help identify possible improvements in the design of care for women and newborns in the United States.

The costs of training a Nurse Practitioner in primary care: the importance of allowing for the cost of education and training when making decisions about changing the professional-mix

What is already known on this topic * Cost containment through the most effective mix of staff achievable within available resources and organisational priorities is of increasing importance in most health systems. However, there is a dearth of information about the full economic implications of changing skill mix. * In the UK a major shift in the primary care workforce is likely in response to the rapidly developing role of nurse practitioners and policies aimed to encourage GP practices to transfer some of their responsibilities to other, less costly, professionals. * Previous research has developed an approach to incorporating the costs of qualifications, and thus the investment required to develop a skilled workforce, for a variety of health service professionals including GPs. What this study adds * This paper describes a methodology of costing nurse practitioners that incorporates the human capital cost implications of developing a skilled nurse practitioner workforce. With appropriate sources of data the method could be adapted for use internationally. * Including the full cost of qualifications results in nearly a 24 per cent increase in the unit cost of a Nurse Practitioner. * Allowing for all investment costs and adjusting for length of consultation, the cost of a GP consultation was nearly 60 per cent higher than that of a Nurse Practitioner.

Multidisciplinary primary care teams: effects on the quality of clinician-patient interactions and organizational features of care

BACKGROUND

Multidisciplinary teams may hold promise for improving primary care quality. This study examined the influence of multidisciplinary teams on patients' assessments of primary care, including access, integration, and clinician-patient interaction quality.

METHODS

From January 2004 through March 2005, a large multispecialty practice in Massachusetts obtained data monthly from patients of 145 primary care physicians using a well-validated patient questionnaire. The analytic sample included respondents with at least 2 primary care visits over the study period (n=14,835). For each respondent, administrative data were used to compute visit continuity over the study period and to classify each primary care visit as PCP, on-team, or off-team. Multivariate regression modeled the relationship of visit continuity to each primary care measure.

RESULTS

Approximately one-third of patients (35%) saw only their PCP; 15% had only PCP and "on-team" visits; 9% had a mix of PCP, on-, and off-team visits; and 41% had only "off-team" visits when not seeing their PCP. Greater PCP continuity was associated with more favorable scores on nearly all measures (P<0.001). An exception was patients' assessments of teams, which were better when on- versus off-team visits occurred (P<0.01). For other measures, the decrements associated with discontinuity were the same irrespective of whether discontinuities involved on- or off-team visits.

CONCLUSIONS

The finding that PCP visit discontinuities are associated with more negative care experiences, irrespective of whether discontinuities involve on- or off-team visits, highlights the challenges of incorporating teams into primary care in ways that patients experience as value-added rather than disruptive to primary care relationships.

Sub-Saharan Africa: beyond the health worker migration crisis?

Migration of skilled health workers from sub-Saharan African countries has significantly increased in this century, with most countries becoming sources of migrants. Despite the growing problem of health worker migration for the effective functioning of health care systems there is a remarkable paucity and incompleteness of data. Hence, it is difficult to determine the real extent of migration from, and within, Africa, and thus develop effective forecasting or remedial policies. This global overview and the most comprehensive data indicate that the key destinations remain the USA and the UK, and that major sources are South Africa and Nigeria, but in both contexts there is now greater diversity. Migrants move primarily for economic reasons, and increasingly choose health careers because they offer migration prospects. Migration has been at considerable economic cost, it has depleted workforces, diminished the effectiveness of health care delivery and reduced the morale of the remaining workforce. Countries have sought to implement national policies to manage migration, mitigate its harmful impacts and strengthen African health care systems. Recipient countries have been reluctant to establish effective ethical codes of recruitment practice, or other forms of compensation or technology transfer, hence migration is likely to increase further in the future, diminishing the possibility of achieving the United Nations millennium development goals and exacerbating existing inequalities in access to adequate health care.

Evolution of practice nursing in Australia

AIM

This paper describes the evolution of Australian practice nursing and documents seminal events in crystallizing the importance of the nursing role in general practice.

BACKGROUND

Internationally, the potential for nurses to improve health in primary care settings is acknowledged. The general practice setting is a focal point for primary care in many health systems. Despite the important role played in the delivery of primary health care by nurses working in general practice in the United Kingdom and New Zealand, the role of nurses in Australian general practice is much less clearly defined, as reflected by the paucity of research and scholarship in this area. Fuelled by the increasing challenges of workforce shortages and the increasing need for multidisciplinary care, interest in the developing role of the Australian practice nurse among clinicians, researchers and policy makers is increasing.

DISCUSSION

Australian practice nursing has reached a critical point in its evolution. It is imperative for the promotion of nursing in general practice that knowledge from descriptive, exploratory research be used to inform strategic decision-making in terms of professional development issues, policy, research and scholarship. These data also need to inform systematic outcome studies. To date, the embryonic nature of practice nursing as a discrete professional entity in Australia has inhibited its representation in nursing curricula and professional bodies.

CONCLUSION

In order to advance the Australian practice nurse movement and demonstrate its important contribution to primary health care, nurses need to take the lead in strategic planning of this emerging specialty. As well as leadership from an academic, research and policy perspective, clinical leaders need to be fostered among the ranks of practice nurse clinicians to drive clinical practice development and the delivery of evidence-based primary care.

Effectiveness of general practice nurse interventions in cardiac risk factor reduction among adults

BACKGROUND

Cardiovascular disease is the leading cause of death for adults in Australia. In recent years there has been a shift in health service delivery from institutional to community-based care for chronic conditions, including cardiovascular disease. The general practice setting is seen to offer greater flexibility, higher levels of efficiency and more client focused healthcare delivery than is possible in the acute care sector. It has been suggested that practice nurses represent a useful adjunct to current models of cardiovascular disease management. To date, significant descriptive research has been conducted exploring the demographics, roles, educational needs and issues facing practice nurses. However, there is a need to evaluate the effectiveness of practice nurse interventions in terms of patient outcomes, clinician satisfaction and cost-effectiveness.

OBJECTIVES

This review seeks to present the best available evidence regarding the efficacy of general practice nurse interventions for cardiac risk factor reduction in healthy adults, as well as those with established cardiovascular disease or known cardiac risk factors.

SEARCH STRATEGY

A systematic literature search was performed using Medline (1966 - 2005), CINAHL (1982 -2005), Cochrane Controlled Trials Register (Issue 4, 2005) and the Joanna Briggs Institute Evidence Library. In addition, the reference lists of retrieved papers, conference proceedings and the Internet, were scrutinised for additional trials.

SELECTION CRITERIA

This review considered any English language randomised trials that investigated interventions conducted by the practice nurse for cardiovascular disease management or reduction of cardiac risk factors. Interventions conducted by specialist cardiac nurses in general practice were excluded. Outcomes measured included blood pressure, smoking cessation, total cholesterol, exercise, body weight/body mass index and cost-effectiveness.

RESULTS

Eighteen trials, reported in 33 papers, were included in the review. Ten trials investigated multifaceted interventions, while the remaining eight trials reported targeted interventions. Of the trials that reported multifaceted interventions, three trials investigated risk reduction in those with established cardiovascular disease, four trials focused on those with known cardiovascular disease risk factors and three trials included the general community. The eight trials which examined the efficacy of targeted interventions focused upon dietary intake (two trials), smoking cessation (three trials), weight reduction (one trial) and physical activity (two trials). The effect of both the multifaceted and targeted interventions on patient outcomes was variable. However, both the multifaceted and targeted interventions demonstrated similar outcome trends for specific variables. Improvements were demonstrated by most studies in blood pressure, cholesterol level, dietary intake and physical activity. The variation in outcome measures and contradictory findings between some studies makes it difficult to draw definitive conclusions.

CONCLUSIONS

While interventions to reduce cardiovascular disease risk factors have produced variable results, they offer significant potential to assist patients in modifying their personal risk profile and should be developed. The public health importance of these changes is dependant upon the sustainability of the change and its effect on the health outcomes of these individuals. Further well-designed research is required to establish the effectiveness of practice nurse interventions for cardiovascular disease management and risk factor reduction in terms of patient outcomes and cost-effectiveness.

Teleconsultation for cardiac patients: a comparison between nurses and physicians: the SHL experience in Israel

The absence of randomized studies on sufficiently large patient cohorts precludes the drawing of any firm conclusions on the comparative performance between nurses and physicians in transtelephonic triage and consultations and in diagnostic and management decision-making. We conducted such a comparative study at the SHL telemedicine facility. This facility also provides face-to-face medical management for its subscribers by means of mobile intensive care units (MICUs) staffed by physicians. The outcome of calls that came between 7:00 AM and 11:00 PM throughout the study year and that were handled at random by specially trained physicians (n = 15) or nurses (n = 35) were analyzed. Of 48,707 subscribers who fulfilled the study entry criteria 25,106 used the service at least once, producing 88,103 calls (81,817 handled by nurses and 6,286 by physicians). Teleconsultations were sufficient for most of the cases (80.13%). There were no significant differences between the performance of nurses and physicians regarding demographics (age, gender) and medical diagnoses of the applicants. The nurses' performance and decisions were comparable to those of physicians with respect to teleconsultations, medically justified dispatches of an MICU, repeated calls to the center and mortality during the week after the index call, although the duration of the physicians' telephone consultations was longer. Delegation of equal authority to nurses and physicians in triage and consultation in telecardiology results in equivalent and highly satisfactory medical care in a system in which subscribers receive service orchestrated from a single center of telecommunications.

Change on the horizon: issues and concerns of neophyte advanced healthcare practitioners

AIMS AND OBJECTIVES

The aim was to interview new entrants to a Master's level programme of educational preparation for advanced healthcare practice roles. The objectives were to gain an understanding of their issues and concerns as they looked ahead to their future development and to illuminate issues concerning their experiences as students and as employees.

BACKGROUND

As advanced practice roles become more widespread in the United Kingdom and abroad, nurses and other healthcare professionals are becoming more involved in innovation and service development and experiencing greater autonomy in many areas, particularly in regard to clinical examination and diagnosis.

DESIGN

A qualitative design was employed to illuminate issues and concerns of new students on a Master's degree programme of educational preparation for advanced healthcare practitioners.

METHODS

Two focus group interviews were conducted in 2004. Sixteen students from two programme cohorts participated in the two groups.

FINDINGS

Two main themes were outlined. These were: 'opportunities for development' and 'time pressures'. Subcategories within these two themes are also discussed.

CONCLUSIONS

Students undertaking Master's level preparation for advanced healthcare practitioner roles perceive personal and professional benefits and opportunities to develop innovative services to improve patient care as accruing from the programme. These opportunities and benefits were related to the United Kingdom national health policy agenda. Some role difficulties were experienced. The additional burdens that the programme of study provided were an issue for some, but these were perceived as a temporary problem, worth undergoing for the likely long-term benefits.

RELEVANCE TO CLINICAL PRACTICE

Students undertaking educational preparation for advanced practice roles see themselves as innovators, specifically aiming to develop and improve aspects of service provision. Education for advanced practice roles should not be undertaken lightly, but can equip students with various skills, particularly regarding clinical assessment, and these skills should underpin practitioners' autonomy.

A formative evaluation of the potential role of nurse practitioners in a central London HIV outpatient clinic

In-house audit demonstrated that 49% (173/352) of patients attending routine HIV outpatient care are asymptomatic and have needs that could potentially be met by other health care professionals. We therefore evaluated the potential development and acceptability of nurse practitioner roles in contributing to HIV outpatient care. Data were collected through 26 consultation observations, 25 patient interviews, 2 patient focus groups, 22 provider interviews and 8 provider focus groups. Service users were key members of the evaluation team. With increasing HIV incidence and the change in focus of doctor-patient consultations from acute to chronic disease management, there are concerns about the sustainability of easily available routine HIV outpatient appointments using the same model of care that has prevailed over the past 20 years. Nurse practitioner models of care were considered acceptable for asymptomatic patients, including those who do not have complex issues related to highly active antiretroviral therapy (HAART). Key considerations for the role include training, supervision, referral pathways, and a clear understanding of the limitations of nursing practice. There is an emphasis on the need to consider 'new ways of working' throughout the service, rather than merely substituting or transferring clinical roles between professionals. Funding pending, nurse practitioner roles are planned for implementation in late 2004. Evaluation will determine impact on service utilization, health and economic outcomes.

Comparing the cost of nurse practitioners and GPs in primary care: modelling economic data from randomised trials

BACKGROUND

The role of nurse practitioners in primary care has recently expanded. While there are some outcome data available for different types of consultations, little is known about the relative cost.

AIM

To compare the cost of primary care provided by nurse practitioners with that of salaried GPs.

DESIGN OF STUDY

Synthesis, modelling, and analysis of published data from the perspective of general practices and the NHS.

DATA SOURCES

Two published randomised controlled trials.

METHOD

A dataset of resource use for a simulated group of patients in a typical consultation was modelled. Current unit costs were used to obtain a consensus mean cost per consultation.

RESULTS

Mean cost of a nurse practitioner consultation was estimated at 9.46 UK pounds (95% confidence interval [CI] = 9.16 to 9.75 pounds) and for a GP was 9.30 UK pounds (95% CI = 9.04 to 9.56 pounds) according to salary and overheads, that is, from the perspective of general practices. From the NHS perspective, which included training costs, the estimated mean costs were 30.35 UK pounds (95% CI = 27.10 to 33.59 pounds) and 28.14 UK pounds (95% CI = 25.43 to 30.84 pounds) respectively. Sensitivity analysis suggested that the time spent by GPs contributing to nurse practitioners' consultations (including return visits) was an important factor in increasing costs associated with nurse practitioners.

CONCLUSION

Employing a nurse practitioner in primary care is likely to cost much the same as employing a salaried GP according to currently available data. There is considerable variability of qualifications and experience of nurse practitioners, which suggests that skill-mix decisions should depend on the full range of roles and responsibilities rather than cost.

Impact of a nurse practitioner-assisted preoperative assessment program on quality

BACKGROUND

The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient-centered care by instituting a nurse practitioner-assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program.

METHODS

One thousand five hundred and nine children aged 1 month-18 years, 463 parents, 25 anesthesiologists and 20 preoperative clinic nurses were studied. Indicators of quality were incidence of respiratory complications (apnea/hypopnea, laryngospasm, bronchospasm, and supplemental oxygen use in postanesthesia care unit), patient preoperative preparation time and parent and staff (anesthesiologists and preoperative clinic nurse) satisfaction. These indicators were recorded for 1 week every 3 months for 1 year. The first week (baseline) was an anesthesiologist-only preoperative assessment (three anesthesiologists performing approximately 120 evaluations per day). The subsequent four data collection weeks at 3, 6, 9, and 12 months were nurse practitioner (NP)-aided preoperative assessments (one anesthesiologist with six NPs performing approximately 120 evaluations per day).

RESULTS

The incidence of respiratory complications, patient preoperative preparation time, and levels of parental satisfaction did not differ significantly between anesthesiologist-only and NP-aided assessments. However, anesthesiologist and preoperative clinic nurse satisfaction increased significantly postimplementation of the program.

CONCLUSIONS

Our study revealed that within a year of its implementation, the NPAPE program maintained patient safety, timeliness, and a high level of parent satisfaction as well as increased staff satisfaction, while shifting two anesthesiologists to the OR. A NP-assisted preoperative evaluation program can offer operational advantages without compromising care.

Evaluation of NOC Standardized Outcome of “Health Seeking Behavior” in Nurse-managed Clinics

This study evaluated the accomplishment of the Nursing Outcomes Classification (NOC) outcome "Health Seeking Behavior" in 5 nurse-managed clinics. Nurse practitioners and registered nurses rated patients on 11 indicators of health seeking behaviors, and recorded their level of knowledge of the patient. A total of 556 evaluations were collected. Health seeking behavior scores were lowest in a rural county school-based clinic and highest in a federally qualified health center. Ratings increased with nurses' knowledge of patients and for older patients.

Nurse Practitioner competency standards: Findings from collaborative Australian and New Zealand research

BACKGROUND

The title, Nurse Practitioner, is protected in most jurisdictions in Australia and New Zealand and the number of nurse practitioners is increasing in health services in both countries. Despite this expansion of the role, there is scant national or international research to inform development of nurse practitioner competency standards.

OBJECTIVES

The aim of this study was to research nurse practitioner practice to inform development of generic standards that could be applied for the education, authorisation and practice of nurse practitioners in both countries.

DESIGN

The research used a multi-methods approach to capture a range of data sources including research of policies and curricula, and interviews with clinicians. Data were collected from relevant sources in Australia and New Zealand.

SETTINGS

The research was conducted in New Zealand and the five states and territories in Australia where, at the time of the research, the title of nurse practitioner was legally protected.

PARTICIPANTS

The research was conducted with a purposeful sample of nurse practitioners from diverse clinical settings in both countries. Interviews and material data were collected from a range of sources and data were analysed within and across these data modalities.

RESULTS

Findings included identification of three generic standards for nurse practitioner practice: namely, Dynamic Practice, Professional Efficacy and Clinical Leadership. Each of these standards has a number of practice competencies, each of these competencies with its own performance indicators.

CONCLUSIONS

Generic standards for nurse practitioner practice will support a standardised approach and mutual recognition of nurse practitioner authorisation across the two countries. Additionally, these research outcomes can more generally inform education providers, authorising bodies and clinicians on the standards of practice for the nurse practitioner whilst also contributing to the current international debate on nurse practitioner standards and scope of practice.

Prescriptive patterns of nurse practitioners and physicians

PURPOSE

To compare the prescriptive patterns of nurse practitioners (NPs) and physicians in a primary care setting for the treatment of sinusitis, bronchitis, musculoskeletal injury, and back pain.

DATA SOURCES

One hundred charts were reviewed for each condition for a total of 400 charts (200 of the charts were for NP providers, and 200 were for physician providers).

CONCLUSIONS

While the mean scores of the differences in prescriptive patterns were found to be statistically significant in only one instance, the overall findings indicate slight differences in the administration of medications for patients. Additionally, NPs prescribed more over-the-counter medications and provided more nonpharmacotherapeutic interventions for their patients than the physicians.

IMPLICATIONS FOR PRACTICE

The results, although statistically significant in only one category, indicate that NPs may be more cautious in their prescriptive interventions and provide more teaching for patients.

Treatment advice in primary care: a comparative study of nurse practitioners and general practitioners

AIM

This paper reports a study comparing the content of talk about treatments by nurse practitioners and general practitioners in order to understand how this might be related to satisfaction.

BACKGROUND

Studies show that satisfaction with nurse practitioner care is high when compared with that given by general practitioners. Clinical outcomes are similar. Nurse practitioners spend statistically significantly longer on consultations, and spend more time discussing treatments as well as social and emotional aspects of patients' lives.

METHODS

Based on transcripts of audiotaped consultations, clinicians' talk about treatment was compared across 18 matched pairs of nurse practitioner and general practitioner consultations where 'same day' appointments were sought. Case studies of six paired consultations were analysed in depth. The data were collected in 1998 in the United Kingdom.

RESULTS

A statistically significantly greater proportion of nurse practitioners' talk concerned treatments, with talk about how to use treatments and discussion of side effects contributing most to the difference. Nurse practitioners also recommended a greater number of treatments. Qualitative comparison of case study pairs suggested that nurse practitioners demonstrated greater concern with the acceptability and cost of treatments to patients.

CONCLUSIONS

Nurses offered more holistic care to these patients and it is likely that this, and the greater provision of information, led to the higher levels of satisfaction found by other investigators. General practitioners are more focused on gathering information directly relevant to diagnosing and treating the immediate presenting complaint. Both types of practitioner may benefit from seeing the detailed illustrations of different approaches provided.

Patients' assessments of consulting a nurse practitioner: the time factor

AIM

This paper reports a study exploring patients' views about consulting with a primary care nurse practitioner.

BACKGROUND

United Kingdom based randomized controlled trials comparing the work of doctors and nurse practitioners add considerable weight to the view that patients tend to be more satisfied with primary care nurse practitioner consultations. However, there is a need for qualitative research to explore issues raised by the trials.

METHODS

A judgement sample of 10 patients consulting with a primary care nurse practitioner was drawn. In-depth interviews were conducted and analysed thematically. The data were collected in 2000-2001.

FINDINGS

The following themes were identified in the data: time spent in the consultation; and time as a commodity in patients' lives. Time matters to patients when they consult on their health, whether it is time to discuss problems or time saved as a result of having issues resolved, thus minimizing further visits. Factors associated with the style and emphasis of consultations are also important.

CONCLUSIONS

Understanding the relationship between time, and style and emphasis of consultation may help to explain patients' satisfaction with primary care nurse practitioners.

Perceptions of Effectiveness of Nurse-Managed Clinics: A Cross-Cultural Study

OBJECTIVE

To study perceptions of the effectiveness of two nurse-managed clinics (NMCs), one in the United States and the other in New Zealand.

DESIGN

Cross-cultural evaluation study utilizing qualitative methodology; two rounds of in-depth interviews were tape recorded, transcribed verbatim, and analyzed for themes.

SAMPLE

Data were initially collected from 21 participants. Sixteen of the original participants participated in a second interview.

INTERVENTION

The first round of interviews and provisional data analysis were conducted in the respective NMCs; joint data analysis to identify themes and develop a preliminary joint report of findings followed. Sixteen participants responded to the provisional report; additional data analysis resulted in the final report of findings.

RESULTS

Analysis of the data yielded three categories: the NMC milieu affects perceived effectiveness; perceptions are shaped by contrasting with past experiences; and the level of care affects personal health care decisions.

CONCLUSIONS

The milieu created in the NMC enhances perceptions of effectiveness and responsibility for personal health care. Further research related to effectiveness of NMC models of care and client outcomes is needed. Qualitative methodology is recommended for cross-cultural research.

The role of the nurse practitioner in psychiatric/mental health nursing: exploring consumer satisfaction

There is a substantial body of literature pertaining to the role of the nurse practitioner. Research directed towards consumer satisfaction suggests that the care provided by nurse practitioners is perceived as at least equal to that provided by a medical practitioner. However, there is a paucity of literature examining the nurse practitioner role in the psychiatric/mental health field. An evaluation of a Nurse Practitioner demonstration model has recently been undertaken in the Crisis, Assessment and Treatment Team in Victoria, Australia. This article presents the findings of a qualitative, exploratory study. Individual interviews were conducted with consumers (n = 7) who had received care and treatment provided by the nurse practitioner candidate. Data analysis revealed two main themes: the quality of the service provided, and the unique role of the nurse. The findings supported the available literature in articulating the specific aspects of the nurse practitioner role that are favourably perceived by consumers of services. This study contributes to the limited body of knowledge in the psychiatric/mental health nursing field and specifically emphasizes the importance of the relationship between nurse practitioner and consumer in facilitating the provision of effective care and treatment.

Measuring quality in nurse-managed centers using HEDIS measures

Nurse-managed centers (NMCs) provide viable options for primary healthcare and contribute substantially to filling access gaps for vulnerable populations. The purposes of this paper are to (a) describe a pilot application and adaptation of eight Health Plan Employer Data and Information Set (HEDIS) measures to six NMCs, (b) report the findings from the quality assessments, and (c) compare findings to national HEDIS data. The eight quality assessment areas are asthma, cervical cancer screening, childhood immunizations, depression, diabetes, hypertension, mammography screening, and smoking cessation. The NMCs achieved or exceeded HEDIS 50th percentile levels in a number of important clinical areas, but did not attain the 50th percentile level in others. Thus, HEDIS measures are relevant for the assessment of care quality and provide useful data for quality improvement in NMCs.

Evaluating the clinical effectiveness of neonatal nurse practitioners: an exploratory study

AIM AND OBJECTIVES

The aim of the investigation was to establish if there was any preliminary evidence to indicate if the quality of care and clinical outcomes for premature birth babies are affected by the type of practitioner (i.e. nurse practitioner vs. medical practitioner) responsible for the initial assessment, treatment and management of neonates during the first 6-12 hours following admission to a neonatal intensive care unit.

BACKGROUND

The United Kingdom (UK) has seen a proliferation in the number of nurse practitioners in the past decade. While there is a growing body of evidence to suggest that nurse practitioners in primary care settings are able to provide a high quality and effective level of clinical service comparable with many of their medical counterparts, there has been relatively little evaluation of the nurse practitioner role in acute or high dependency hospital settings.

DESIGN AND METHODS

The study design used a mixed method approach combining a retrospective examination and quality assessment of nursing and medical records. A random sample of 61 sets of medical records, relating specifically to the initial management and treatment of neonates were criterion assessed by an experienced consultant neonatologist and a variety of patient outcome data collated and analysed.

RESULTS

The analysis of the patient outcome data and quality assessment of nursing and medical records revealed that there was no statistical difference in the standard and quality of care provided between nurse practitioners and medical staff in the vast majority of areas evaluated. However, trends in the data suggest that Advanced Neonatal Nurse Practitioners (ANNPs) did not perform as well as their medical counterparts in terms of the overall completeness or comprehensiveness of the standard care provided in a number of areas.

CONCLUSION

Neonatal nurse practitioners provide an alternative model of service delivery in the initial admission and management of premature birth babies. While the results of the study suggest that ANNPs do not perform as well as medical staff, in the majority of cases, they still performed to an acceptable standard. Nonetheless, some deficits in the standard of care provided by both groups of practitioners were identified which in turn have implications for ongoing training and skills development. Relevance to clinical practice. The findings suggest that ANNPs are capable of taking on an advanced role in the assessment and management of neonates.